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Fentanyl supply in the city is up and down, while crystal meth remains popular because it's cheap

London's temporary drug overdose prevention site provides these free sanitary single-use cookers to clients. Cookers used multiple times can be a source of bacteria, leading to blood infections like endocarditis. (Andrew Lupton/CBC)

What drugs are clients at London's Temporary Overdose Prevention (TOPS) site using?

That's the question we put to staff of the facility, which has handled almost 5,000 client visits since opening in February.

The list shows that opioids like hydromorphone and fentanyl continue to be in steady use among Londoners who inject drugs.

Sonja Burke is the director of Counterpoint Harm Reduction Services, which operates the site.

She said the drugs on the list didn't surprise her, although she was somewhat surprised that crystal meth didn't appear in the top spot.

The list below is based on anecdotal self-reporting from clients, so Burke cautions that it should not be considered a comprehensive survey. Also, because not all London's drug users visit TOPS, this list can only offer a limited view into which drugs are being consumed locally.

Here's the list:

1. Hydromorphone

​This strong opioid is available in capsule form but users typically crush the capsules down and mix the beads with water for injection. This creates a more intense, immediate high. Unlike its brand-name equivalent Dilaudid (number three on this list) hydromorphone can be injected more than once after the initial mixing. This allows users to get more out of one capsule, but it also increases the chance of infection if residue remains in the bowl (called a cooker) used to mix and heat it. "If a person is using the same cooker multiple times, then it gives the opportunity for the bacteria to grow," said Burke. This can lead to infections like endocarditis and flesh-eating disease.

Along with clean syringes, London's TOPS provides clients with sanitary, single-use disposable cookers to cut down on infections.

A drug user named John who spoke to CBC News said the appeal of hydromorphone is its low price and relatively easy availability.

"It's the time release that makes it really popular," he said. "For $20, it goes a long way."

Kits filled with equipment are laid out for people using injection drugs at London's Temporary Overdose Prevention Site. (Amanda Margison, CBC News)

2. Crystal meth

Also commonly injected, this drug remains popular because at $5 a dose, it's a cheap high. Meth is a popular alternative for users having trouble obtaining opioids like hydromorphone and fentanyl. Burke says meth use spiked when OxyContin — a highly addictive opioid pill commonly crushed down for intravenous use — was replaced by OxyNeo in 2012. OxyNeo can't be crushed down, limiting its appeal for users who want the more intense high that comes from injecting the drug. "When there's nothing else, people turn to crystal meth," said Burke. She said people struggling with homelessness often use meth "to stay alert and awake throughout the night to protect their safety."

3. Dilaudid

​This is the brand name of hydromorphone but it comes in pill form, not capsules. Pills crushed into a powder for IV use can only be used once, which limits their appeal. Still, it's easy enough to get with a prescription, which explains much of its popularlity.

4. Morphine and methadone

These remain more popular among TOPS clients than heroin.

Anecdotal reports from clients who use London's temporary overdose prevention site suggest that the local supply of fentanyl isn't constant. (CBC)

5. Fentanyl

A growing driver of Canada's opioid crisis, fentanyl is deadly not only for its potency but because it's often mixed into other drugs by dealers. Users who take it unknowingly are at risk. "It's also really challenging with powdered fentanyl to know the dosage," said Burke. "People may think it's evenly mixed with another substance and it's not. So one dose may have a small amount and the next dose may have a large amount." Burke also said clients tell her the availability of fentanyl in London isn't constant, but can rise and fall.

Permanent site still a priority

London's TOPS operates out of a cramped space at 186 King St. There have been many successes. Clients are accessing resources, such as addiction counselling. But Burke says moving to a permanent site would improve client care. The Middlesex-London Health Unit has narrowed the search down to two sites.

"Right now we are busy, so we have lots of people in the waiting room," said Burke. But a permanent site "would definitely help us serve more people."

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